Provider Demographics
NPI:1861034571
Name:KELLY, JASON LEE
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:LEE
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 WEST DR
Mailing Address - Street 2:
Mailing Address - City:BRUCETON MILLS
Mailing Address - State:WV
Mailing Address - Zip Code:26525-7487
Mailing Address - Country:US
Mailing Address - Phone:304-841-8355
Mailing Address - Fax:
Practice Address - Street 1:100 WALMART DR
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:WV
Practice Address - Zip Code:26537-1143
Practice Address - Country:US
Practice Address - Phone:304-329-4031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-14
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0007506183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist